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Firearm Legislation and Firearm-Related Fatalities
in the United States
Eric W. Fleegler, MD, MPH; Lois K. Lee, MD, MPH; Michael C. Monuteaux, ScD;
David Hemenway, PhD; Rebekah Mannix, MD, MPH

Importance: Over 30 000 people die annually in the
United States from injuries caused by firearms. Although
most firearm laws are enacted by states, whether the laws
are associated with rates of firearm deaths is uncertain.
Objective: To evaluate whether more firearm laws in a
state are associated with fewer firearm fatalities.
Design: Using an ecological and cross-sectional method,

we retrospectively analyzed all firearm-related deaths reported to the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System from 2007 through 2010. We used state-level firearm
legislation across 5 categories of laws to create a “legislative strength score,” and measured the association of
the score with state mortality rates using a clustered Poisson regression. States were divided into quartiles based
on their score.
Setting: Fifty US states.
Participants: Populations of all US states.
Main Outcome Measures: The outcome measures were
state-level firearm-related fatalities per 100 000 individuals per year overall, for suicide, and for homicide. In various models, we controlled for age, sex, race/ethnicity, poverty, unemployment, college education, population
density, nonfirearm violence–related deaths, and household firearm ownership.

Results: Over the 4-year study period, there were 121 084
firearm fatalities. The average state-based firearm fatality rates varied from a high of 17.9 (Louisiana) to a low
of 2.9 (Hawaii) per 100 000 individuals per year. Annual firearm legislative strength scores ranged from 0
(Utah) to 24 (Massachusetts) of 28 possible points. States
in the highest quartile of legislative strength (scores of
ⱖ9) had a lower overall firearm fatality rate than those
in the lowest quartile (scores of ⱕ2) (absolute rate difference, 6.64 deaths/100 000/y; age-adjusted incident rate
ratio [IRR], 0.58; 95% CI, 0.37-0.92). Compared with the
quartile of states with the fewest laws, the quartile with
the most laws had a lower firearm suicide rate (absolute
rate difference, 6.25 deaths/100 000/y; IRR, 0.63; 95% CI,
0.48-0.83) and a lower firearm homicide rate (absolute
rate difference, 0.40 deaths/100 000/y; IRR, 0.60; 95% CI,
Conclusions and Relevance: A higher number of
firearm laws in a state are associated with a lower rate
of firearm fatalities in the state, overall and for suicides
and homicides individually. As our study could not
determine cause-and-effect relationships, further
studies are necessary to define the nature of this

JAMA Intern Med. 2013;173(9):732-740.
Published online March 6, 2013.


HE TOTAL NUMBER OF ANnual firearm fatalities in the
United States has been
stable over the last decade.1,2 From 2007 to 2010,
the range was 31 224 to 31 672 fatalities
per year.1 There is substantial variation in

Author Affiliations: Division of
Emergency Medicine, Boston
Children’s Hospital, Boston,
Massachusetts (Drs Fleegler,
Lee, Monuteaux, and Mannix);
Harvard Medical School, Boston
(Drs Fleegler, Lee, Monuteaux,
and Mannix); and Harvard
School of Public Health, Boston
(Dr Hemenway).

See Invited Commentary
at end of article
firearm fatality rates among states,
however, with the average annual statebased firearm fatality rates ranging from
a high of 17.9 (Louisiana) to a low of 2.9
(Hawaii) per 100 000 individuals during

JAMA INTERN MED/ VOL 173 (NO. 9), MAY 13, 2013

these years. In 2010, firearms killed 68%
of the 16 259 victims of homicide. In the
same year, there were 38 364 suicides, of
which 51% were by firearms.1 Beyond the
loss of life and nonfatal traumatic injuries, the financial cost of firearm injuries

CME available online at
and questions on page 723
is enormous. In 2005, the medical costs
associated with fatal and nonfatal firearm
injuries were estimated at $112 million and
$599 million, respectively, and work loss
costs were estimated at $40.5 billion.1


©2013 American Medical Association. All rights reserved.

Downloaded From: by Lucas Silveira on 01/06/2018

Author Affil
Emergency M
Children’s H
Lee, Monute
Harvard Med
(Drs Fleegle
and Mannix
School of Pu
(Dr Hemenw